The Chicago Department of Public Health (CDPH) has a vision of a city of thriving communities where all residents are able to live healthy lives. The City of Chicago is located in Illinois on the western shore of Lake Michigan. It is home to nearly 3 million people across 234 square miles. Demographically, Chicago's population is roughly one-third White, one-third Black/African-American, and one-third Hispanic/Latinx. Almost one-quarter of Chicagoans live below the poverty line.
Overdose deaths involving opioids rose from 426 in 2015 to 741 in 2016, an increase of 74%. Those dying from opioid-related overdose deaths are more likely to be men, 45-64 years old and Black/African American. The rate of overdose deaths involving heroin was higher than the rate of deaths involving other types of opioids. One factor in preventing future opioid-related overdose deaths is providing evidence-based treatment for opioid use disorder. Like many other chronic conditions, people often need life-long support to be able to effectively manage opioid use disorder.
Buprenorphine and methadone are highly effective medications for treatment of opioid use disorder. Increased access to these medications has been shown to significantly reduce opioid-related mortality. Access and uptake remain limited nationwide, with only one-third of treatment plans for opioid use disorder including medications. Unlike methadone, buprenorphine can be prescribed in a medical office by any medical provider with a waiver under the Drug Addiction Treatment Act of 2000 (DATA 2000). Therefore, there are more opportunities to expand access to buprenorphine. CDPH has prioritized increasing access to buprenorphine to address the increasing overdose deaths due to opioids in Chicago.
After assessing interest, CDPH hosted a learning collaborative (LC) among the federally qualified health centers (FQHCs) and other interested health systems in the City of Chicago. The goal was to increase access and capacity for buprenorphine in office-based settings, by facilitating conversation and knowledge sharing, providing access to addiction treatment experts, assisting in incorporation of evidence-based practice, and supporting efficient training. Unlike many existing education and technical assistance programs, this LC included a specific decision-maker track that focused on a novel participant-driven approach to helping health system leadership build systems to support staff and implement system-wide best practices.
The decision-maker track consisted of quarterly, half-day in-person meetings from July 2017—June 2018. Decision-maker sessions combined participant presentations and group discussions. Topics were selected from surveys of participants, creating an evolving, participant-driven process.
In spring 2017, health systems shared information about baseline service capacity, including number of prescribers with a DATA waiver, number of providers actively prescribing, number of patients on buprenorphine, and presence of various workflows and protocols. The same systems-level metrics were again collected at the final decision-maker session (spring 2018). After each session, individual participants completed online evaluations of session format and presentations. The final evaluation included in-depth questions about the overall utility of the LC.
Fifteen separate health systems participated in the LC decision-maker track. There were 38 unique participants with an average of 21 attendees per decision-maker track session.
Health systems-level metrics were compared pre- and post-LC from the 11 health systems that participated for the entire year. Two health systems had not begun prescribing buprenorphine when the LC concluded. All other clinics showed increases in the number of providers actively prescribing buprenorphine, the number of active patients receiving buprenorphine, and the number of locations prescribing buprenorphine. In total, across all 11 health systems, there was a 52% increase in the number of prescribers with DATA waivers (from 79 to 120), an 84% increase in the number of providers prescribing buprenorphine (25 to 46), and a 68% increase in the number of locations prescribing buprenorphine (25 to 42).
Sixteen decision-makers (42% of decision-makers) completed the final post-decision-maker LC track evaluation. These respondents strongly agreed (3.9 on 4-point scale) that their organization benefited from their attendance. Every respondent agreed or strongly agreed that the collaborative impacted their work and they would return if the collaborative were continued. Additionally, the surveys after each meeting indicated that each meetings objectives as well as overall objectives were met.
Given that some health systems had already committed to expanding buprenorphine access as a part of a separate grant, it is possible that the combination of established buy-in and financial support coupled with our quarterly meetings and support contributed to the success. Additionally, the participant-driven nature of the LC may have contributed to its success, in that attendees could bring up actual issues and leave with possible solutions, having heard from colleagues direct experiences with the same issues.